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Reply to the letter by M Ayas

Bone Marrow Transplantation volume 31, page 313 (2003)Cite this article

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Ayas and co-workers report encouraging prevention of GVHD when ATG is used as an adjunct for GVHD prophylaxis in patients with Fanconi Anemia. They conclude that ATG may be considered in patients at high risk of GVHD, although EBV-associated lymphoproliferative disorders remain a problem. We would agree that ATG reduces acute and chronic GVHD, when given within the conditioning regimen, as shown by a randomized trial we have recently published.1 The effect of ATG seems to be dose dependent, with stronger prevention of GVHD when giving higher doses of ATG.1 However, there is a limit to the amount of ATG one can give to patients before the transplant, and patients receiving a high dose of ATG (15 mg/kg of Thymoglobuline Sangstat), especially if grafted from an alternative donor, are at greater risk of severe infections,1 owing to impaired immune reconstitution. EBV lymphomas are an additional matter of concern. That is why we have taken the somewhat different approach of giving a smaller dose (7.5 mg/kg) pretransplant, and then treat only patients who can be identified as being at high risk on the basis of objective laboratory data.2 This is what we call pre-emptive treatment of GVHD, and a randomized trial is now ongoing to prove whether this different approach can not only prevent GVHD, but also reduce transplant mortality. We agree with Ayas and co-workers that ATG prevents GVHD, and should be considered in patients at greater risk because of stem cell source (peripheral blood), donor type (unrelated, alternative) or diagnosis (Fanconi Anemia, chronic myeloid leukemia).

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References

  1. Bacigalupo A, Lamparelli T, Bruzzi P et al. Antithymocyte globulin for graft-versus-host disease prophylaxis in transplants from unrelated donors: 2 randomized studies from Gruppo Italiano Trapianti Midollo Osseo (GITMO). Blood 2001; 98: 2942–2947.

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  2. Bacigalupo A, Oneto R, Bruno B et al. Early predictors of transplant-related mortality (TRM) after allogeneic bone marrow transplants (BMT): blood urea nitrogen (BUN) and bilirubin. Bone Marrow Transplant 1999; 24: 653–659.

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  1. Divisione Ematologia 2 (PAD 5/11), Ospedale San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy

    Andrea Bacigalupo

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  1. Andrea Bacigalupo
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Bacigalupo, A. Reply to the letter by M Ayas. Bone Marrow Transplant 31, 313 (2003). https://doi.org/10.1038/sj.bmt.1703805

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